Financial Assistance

Date

MM

DD

YYYY

Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Spouse's Information

First Name

Last Name

Spouse's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Spouse's Phone

(###)

###

####

Please list specific request(s) needed at this time:

Food

Rent/Housing Payment

Utility Bill

Clothing

Prescriptions

Other

Do you currently have a social worker?

Yes

No

Social Workers Name

First Name

Last Name

Social Workers Phone

(###)

###

####

Have you previously received assistance from Christian Life Center?

Yes

No

Referral's Number

(###)

###

####

Have you contacted anyone else for assistance within the last 6 months?

Yes

No

Your home church address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Minister/Pastors Phone Number:

(###)

###

####

Do you attend church regularly?

Yes

No

Since when?

MM

DD

YYYY

Are you a member?

Yes

No

Have you received assistance from your church?

Yes

No

When?

MM

DD

YYYY

Are you a current volunteer at CLC?

Yes

No

Reference Name #1

First Name

Last Name

Reference #1 Number:

(###)

###

####

Reference Name #2

First Name

Last Name

Reference #2 Number

(###)

###

####